What are the recent advances in managing a patient with ankylosing spondylitis?

Recent Advances in Management of Ankylosing Spondylitis

The most significant recent advance in AS management is the introduction of anti-TNF biological therapy for patients with persistently high disease activity despite NSAIDs, which has revolutionized treatment outcomes for refractory disease. 1

First-Line Pharmacological Treatment

NSAIDs remain the cornerstone first-line treatment and should be used continuously rather than intermittently in patients with persistently active disease. 1

• Level Ib evidence demonstrates NSAIDs improve spinal pain, peripheral joint pain, and function over 6 weeks 1
• Continuous NSAID treatment is preferred over "on-demand" use, as emerging evidence suggests it may retard radiographic disease progression at 2 years 1
• For patients with increased gastrointestinal risk, prescribe either non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor 1

Common pitfall: Clinicians often use NSAIDs intermittently to minimize side effects, but this approach may compromise disease control and potentially allow radiographic progression. 1

Non-Pharmacological Interventions

Patient education and regular exercise should be initiated immediately and continued throughout the disease course. 1

• Level Ib evidence supports home exercise improving function in the short term 1
• Group physical therapy demonstrates better patient global assessment outcomes compared to home exercise alone 1
• These interventions are foundational and should never be delayed or omitted 2

Biological Therapy: The Major Advance

Anti-TNF therapy should be initiated in patients with persistently high disease activity despite conventional NSAID treatment. 1

Key Points About Anti-TNF Therapy:

• All TNF inhibitors (infliximab, etanercept, adalimumab) show equivalent efficacy for axial and articular/entheseal manifestations with level Ib evidence supporting large treatment effects over at least 6 months 1
• No DMARD use is required before or concomitant with anti-TNF therapy for axial disease 1
• For patients with concomitant inflammatory bowel disease, monoclonal antibody anti-TNF agents are strongly recommended over etanercept 2

Critical distinction: Unlike rheumatoid arthritis, AS does not require a trial of DMARDs before initiating biologics—patients can proceed directly from NSAIDs to anti-TNF therapy if disease activity remains high. 1

Newer Biological Agent: IL-17 Inhibition

Secukinumab (IL-17A inhibitor) represents a recent therapeutic advance, particularly for patients who fail or are intolerant to anti-TNF therapy. 3

• At Week 16, secukinumab 150 mg achieved ASAS20 response in 61% of patients versus 28% with placebo 3
• ASAS40 response was achieved in 36% versus 11% with placebo 3
• Secukinumab demonstrated significant improvements in patient global assessment (mean change -27.7 vs -12.9), total spinal pain (-28.5 vs -10.9), and BASFI scores (-2.2 vs -0.7) 3
• The drug is effective regardless of concomitant methotrexate or sulfasalazine use 3

Disease Monitoring Advances

Disease monitoring should include patient history (questionnaires), clinical parameters, laboratory tests, and imaging according to the ASAS core set. 1

• Spinal radiographs should not be repeated more frequently than every 2 years unless clearly indicated in individual cases 1
• Assessment should evaluate disease activity/inflammation, pain levels, function, disability, structural damage, and comorbidities 4

Management of Extra-Articular Manifestations

Extra-articular manifestations including uveitis, inflammatory bowel disease, and vasculitis must be managed in collaboration with respective specialists. 1

• Anti-TNF agents are particularly indicated for patients with vasculitic manifestations as they can treat both AS and vasculitic features simultaneously 2

Surgical Interventions

Total hip arthroplasty should be considered in patients with refractory pain or disability and radiographic evidence of structural damage, independent of age. 1

• Spinal corrective osteotomy may be considered for patients with severe disabling deformity 1
• These interventions remain important for advanced disease despite improved medical therapies 4

Treatment Algorithm

1. Initiate immediately: Patient education + regular exercise program 1
2. First-line pharmacological: Continuous NSAIDs (with gastroprotection if GI risk factors present) 1
3. If persistently high disease activity despite NSAIDs: Initiate anti-TNF therapy without requiring DMARD trial 1
4. If anti-TNF failure/intolerance: Consider IL-17 inhibitor (secukinumab) 3
5. Monitor: Clinical assessment every 3-6 months; radiographs every 2 years 1
6. Surgical consultation: For refractory hip disease or severe spinal deformity 1

The paradigm shift: The availability of highly effective biologics has transformed AS from a condition managed primarily with symptomatic therapy to one where disease modification and prevention of structural damage are achievable goals. 1